Vitals gone wild!
Patient with a diagnosis of heart failure should have what measured at every visit
what is
weight (documented)
reported to MD if outside of parameters or gains more than 2 lbs in a day or 5 lbs in a week
A PTA is seeing a patient living in an ALF. The patient reports having a fall last night in the bathroom but was able to get up on their own. They deny any pain and did not hit their head. who should the PTA notify?
Who are
The ALF staff
The case manager and or their supervising PT
care team
the MD/provider
Kara/office (to make sure fall follow up gets scheduled)
What should you include in you care coordination documentation?
Who you notified
What you notified them of
and what their response was? any changes to POC or orders?
Patient experiences a significant change in condition. what should the clinician do?
Call the provider
notify care team
and document
before calling the doctor, what should the clinician have?
complete, relevant, clinical information
SBAR
patient reports a pain level of 8/10. what should you do?
try interventions for pain
call the doctor to report the level of pain
Document in care cooredination
What do you need to get on a non-protocol admit before you see the patient again?
a verbal order on your plan of care.
a signed order on your plan of care
A patient reports to the therapist that he stopped taking his lasix because he doesn't like to have to get up to go to the bathroom constantly. what should you do?
notify the doctor, notify the care team, document it in care coordination. do a med error report
the PTA notices that a patient has a new edema in their legs. what should they do
What is notify the doctor, notify the care team. Document it!
You notified the doctor that your patient has an elevated blood pressure what should you do next?
Document it!
The patient checks their glucose level during your visit and it read 540. you call the doctor and they have you send the patient to the hospital. where should you document the call to the doctor?
care coordination
Your patient fell while walking to answer the door for your visit. after assessing the patient safely what should you do?
notify the doctor, notified the care team, document it.
What is a communication tool that helps organize information when communicating to the MD and other care team members?
What is SBAR
You have a protocol patient with an elevated heart rate. you attempt to call the doctor but only get a voicemail. what should you do next?
leave a message
contact sales person over this account
if all else fails write a clinical note
AND DOCUMENT all of it!
you admitted a patient and attempted to call the doctor on your plan of care approval. you were unable to reach anyone, so you wrote a clinical note. when can you go see the patient next?
when you get a call back, when you receive the signed clinical note back.
need verbal or written approval of care plan
When should you communicate a vital sign that is out of parameters?
what is ASAP
while in your visit
You patient forgot to take their medications the last two days. what wshould you do?
notify the doctor, notify the care team. document it in care coordination, do a med error report
you Called the doctor after your visit and notified the3m of a patient change in condition. but did nothing else... what happened?
it didn't happen, you never called the doctor.. because if you don't document it didn't happen.
Communicating important patient information yourself instead of assuming someone else will is?
what is accountability
what did Jordan and his wife name their little boy?
Bentley